Proton Therapy Myth 5

Myth #5: If you have surgery and it fails, you can always have proton afterward. But if you have proton first and it fails, you cannot have surgery.

One scare-tactic urologists often use to persuade their patients to do surgery is this: “If you have surgery and it fails, you can always have radiation later, but if you choose radiation, you’ll never be able to have surgery.”

The Facts

Yes, there are some recurrences with proton therapy, however very few and it’s usually, but not always, the advanced cases and more aggressive cancers. But let’s look at it carefully.

When there is a recurrence after proton therapy the first thing to do is consider the age of the patient and the velocity of the PSA increase, or doubling time. Recurrences that happen many years after treatment are often indolent, slow growing cancers that might never cause any problems.

If the PSA doubling time is long, the patient, with his doctor’s support, may choose to do active surveillance, as he would likely die of something other than prostate cancer long before any symptoms would show up.

But let’s assume this is not the case; the patient is relatively young, and the PSA velocity is of concern. The first thing doctors would do is to run a series of tests to determine the location of the recurrence.

Recurrence Outside the Prostate

If tests show the recurrence is outside the prostate, this means there apparently is no cancer within the prostate and therefore no reason to remove it. It also means that even if the prostate had been removed surgically, there would have been a recurrence.

When there is a recurrence outside the prostate, the most common treatment prescribed is hormonal therapy. There are several different hormones used, and each case is different. Hormones may be used individually or in combinations. They could be used continuously, or intermittently. Intermittent Hormonal Therapy (IHT) is becoming more common for treating prostate cancer that has recurred after any form of treatment. Many, if not most, respond well to this treatment for extended periods of time.

Recurrence Inside the Prostate

Once again, testing must be done to determine the location of the recurrence. If inside the prostate, the patient has several options, including cryotherapy, high intensity focused ultrasound (HIFU), brachytherapy, active surveillance, and … salvage radical prostatectomy. Yes, surgery.

Salvage radical prostatectomy (SRP) is more challenging after any form of radiotherapy, but it can be done and has been done by doctors who specialize in this procedure.

Bottom Line

Don’t choose your treatment on the basis of what to do if it fails. Choose the treatment that you believe gives you the best chance of a cure and the best quality of life after treatment.

All the data shows that proton therapy cures cancer at least as well as surgery, and we would argue better because proton destroys cancer in the margins and surgery does not.

We have heard on many occasions from recently diagnosed men, “My urologist tells me that the only way I can be sure of a cure is by having my prostate removed.” Our response is, “That’s interesting. Because when Bob Marckini was being treated almost 13 years ago, he met a lot of men who were having salvage proton therapy following failed surgery.” Most likely, it was cancer in the margins that gained a foothold and continued growing.

Why would anyone choose a treatment that has the potential of complications from anesthesia, infection, trauma, blood loss, catheterization for two to three weeks, slow recovery, and high incidence of impotence and incontinence … when you can choose an alternative that involves no invasive procedure, no pain, no blood loss, no trauma, and significantly fewer side effects, if any? Seems like a no-brainer.

So, next time you hear someone say that you can have radiation after surgery, but you can’t have surgery after radiation, be sure to tell them they are misinformed.